Our Team

About UsRTW Integrated Health Management (RIHM)

Indigenous Mental Health andFetal Alcohol Effects Clinic

Criminal Justice Diversion and Improving Independent Living,Educational & Vocational Outcomes of At-risk Youth/Offenderswith Neurodevelopmental Disorders: Towards a Brief, Cost-efficientcognitive screening for K-8 and correctional institutions

Related literature

FASD:A Holistic Perspective

C.P Shah MD, FRCPC, O.Ont.

FASD Coordinator

Anishnawbe Health Toronto

Professor Emeritus, University of Toronto

Danielle Woodcock, BASc.

Social Work Graduate Student

University of Toronto

Dr. J. Douglas Salmon, Jr.

RTW Integrated Health Management

Dr. Dr. Chandrakant P. ShahBio

FASD Assessment:

What is Involved?

STEP 1: FASD Support Worker

Coordinates team and clinic dates

Ensures smooth flow of diagnostic process

Tracks status of file

Ensures reports are faxed to other agencies.

Involved in follow-up support with family

STEP 2: Social Worker

Gathers information about current functioning

Provision of appropriate support programs

Provision of information, resources & support

STEP 3: Medical Assessment

Physical examination: face, height, andweight

Review of medical records

Review of information about birth mother’sdrinking history

May refer to specialists (i.e. audiologist)

STEP 4: Neuropsychological Assessment

1st stage: interview with Clinical Psychologist(information gathering)

2nd stage: in-depth testing

(tests of functioning)

STEP 5: Traditional Healer

Balance, harmony and good health

Listen, help ,and give support

STEP 6: Speech and Language/Audiology

Assessment addresses concerns regardinghearing impairment, sensitivity to sound anddelays in development and communication

STEP 7: Evaluation and Diagnosis

Case conference with multi-disciplinary FASDteam; Care Plan

Challenges of FASD Diagnosis

Obtaining accurate history of maternalconsumption of alcohol

Expertise in Diagnosis: Necessary Team;Need for Competency; Wrong diagnosis

Availability of Resources following diagnosis

Ongoing Assessment in Future

Dealing with Criminal Justice System

Cognitive Features of FASD

Distractibility and Disorganization

Memory problems (i.e. storing/retrieving information)

Inconsistent performance

Impulsivity

Slow auditory pace

Developmental lags

Ability to repeat instructions but inability to turn theminto action

Difficulty with abstractions (i.e. math, time, money)

Inability to predict outcomes or understandconsequences

FASD: Secondary Disabilities

BEHAVIOURAL

MENTAL HEALTH

ADAPTIVE AND EXECUTIVEFUNCTIONING

Behavioural

Antisocial behaviour

Delinquent behaviour

Classroom/school behaviour

Learning behaviours

Externalizing behaviours

Aggressive behaviour

Criminal activity

Maladaptive behaviour

Impulsivity

Teasing/bullying

Dishonesty

Avoiding schoolwork

Sexual inappropriateness

Self-injury

Substance use

Mental Health

Emotional disorders

Conduct disorders

Sleep disorders

Abnormal habits

Other psychiatric disorders

(PTSD, OCD,

Oppositional Defiant

Disorder)

Substance Use

Mood Disorder

Bipolar Disorder

Depression

Anxiety

Panic Disorder

Hyperkinetic Disorders

Attention-Deficit Hyperactivity

Disorder (ADHD)

Adaptive &Executive Functioning

Socialization

Employment Difficulties

Independent Living Difficulties

Inhibitory Control

Cause and Effect Reasoning

Planning and Organization

Learning from mistakes

Vulnerability to Manipulationand Victimization

Relationship BetweenSecondary Disabilities

In one study of 415 individuals with FAS/FAE:

90% had mental health problems

49% of adolescents/adults and 39% of childrendemonstrated inappropriate sexual behaviour

14% of children and more than 60% ofadolescents/adults had disrupted schoolexperience

14% of children and 60% of adolescents/adultshad been in trouble with the law

1 in 3 adolescents/adults had substance-related problems

School Difficulties

Difficulty or inability to empathize and anticipatethe consequences of their actions

Lack an understanding of social life and whatconstitutes appropriate behaviour in differentsituations

Inability to comprehend another person’s state ofmind

Deficits in concept formation, response inhibition, andself-regulation

Constraint on the amount of information that can beprocessed when presented with complex situations

Fine-motor and visual-motor impairments

Criminal Activity

More likely to associate with delinquent peers

May be easily led by others due to desire tobe accepted

Likely to be influenced by others

Poor executive functioning leads toimpulsivity as well as an inability to foreseeconsequences and learn from mistakes

Having additional disorders, such as asubstance use disorder, increases risk

The Criminal Justice System

Prevalence of people with FASD in CJSappears to be disproportionately higher thanin general population

Annual individual cost of FASD estimated at$21 642.

This estimation does not take into account:costs of crime itself, policing, court, anddisposition

Implications

Individuals with FASD often have difficultyunderstanding questions and providing accurate answers

FASD needs to be accommodated in the CJS in

order for those affected to receive fair treatment andappropriate support

Alternative processes (i.e. diversion , sentencing circles, orrestorative justice approaches) may be more appropriate

Without appropriate support, offenders with FASD mayreturn to the community “worse off” due to amisunderstanding of their FASD and victimization

Secondary disabilities (i.e. mental health and substanceuse) need to be recognized and treated within the CJS

The transition from jail to community requires support fromeveryone involved with the individual (i.e. correction officers,the community, and caregivers)

Interventions

HAVING A MENTOR Individuals with FASD often have few people

in their lives who advocate for their needs Mentor’s can provide structure and order They can also act as the individuals “external

brain”, providing support with judgment andadaptive skills

Mentors can: advocate for clients, overseedaily activities, acquire livingaccommodations, help manage money, offeradvice and encouragement, keep track ofappointments/vocational responsibilities,ensure safety and protection, etc.

Case Review #1

Demographics: Male, 34 years of age

Characteristics:

Charged with aggravated assault while intoxicated

Anger management issues

Poor tolerance of stress

Very few resources/sources of support

Constant suicidal ideations

Uncomfortable in social situations

Feelings of loneliness and depression

Final Diagnosis: ARND and Alcohol Abuse

Mental Health

In a 1996 study of adults with Pre-natal AlcoholExposure (PAE):

94% reported Mental Health problems

43% reported previous suicide threats

23% reported a history of suicide attempts

Depression & Anxiety In adolescents, Pre-natal alcohol exposure

is associated with alcohol problems andincrease psychiatric disorders and traits

Depression and anxiety are among the mostcommonly reported mental health problemsin children and adults with FASD

A direct relation between parental alcoholexposure and child depressive symptoms hasbeen reported

Other factors may play a role: early maternaldeath, living with an alcoholic parent, childabuse and neglect, removal from home, etc.

Psychiatric Symptoms

Persistent psychiatric impairments amongchildren may be related to environmentalfactors (i.e. institutions and foster care)

Cognitive impairments and psychiatricsymptoms are generally persistent and mayincrease

In a recent study (Steinhausen and Spohr),found that 63% of their sample had beendiagnosed with one or more psychiatricdisorders (attention and social problemsnoted by parents and teachers as mostfrequent)

ADHD Effects of prenatal alcohol exposure disturb

the development of the fetal brain Those affected can have difficulty in mood

regulation, self soothing, hypersensitivity tostimuli, irritability and hyperactivity

These individuals can present a primaryregulatory disorder from birth (with difficult tosettle or slow to warm temperament) followed byearly-onset ADHD

In children with FASD, ADHD often presents assecondary developmental, psychiatric, andmedical conditions

Types of ADHD

DSM-IV identifies three subtypes of ADHD:

1. Predominantly Inattentive Type

2. Predominantly Hyperactive-Impulsive Type

3. Combined Type

Vulnerability

In one study, Clark et al. found that: 92% of participants were identified by their

caregivers as “vulnerable to manipulation”(Vulnerability to manipulation can haveimplications for adults in criminal justice system)

87% of participants had been a victim of someform of violence

77% of participants had experienced physicaland/or sexual abuse

Case Review #2Demographics: Male, 6 years of age

Characteristics:

Fine motor difficulties

Impulsive, hyper-active, short attention span

Difficulty creating social boundaries as well as sharing andplaying with peers

Aggressive

Difficulty controlling behaviour

Ongoing parental substance use

Past child abuse and neglect

Final Diagnosis:

Sentinel Physical finding(s)/ Neurobehavioural disorder(PAE) and ADHD (combined type)

Sleep Difficulties

Studies over the last 20 years show therelationship between sleep difficulties and theseverity of cognitive loss and braindisturbance

Most disturbances are described bycaregivers as: difficulties falling asleep,frequent awakenings during the night, andearly morning awakenings

Behavioural manifestations: hyperactivity,aggressiveness, inattentiveness, impulsivity,depression, and other mood disorders

Sleep Sleep disturbances should be treated early and

appropriately as they lead to neurocognitivebehavioral and health difficulties

Intervention services may be ineffective due to sleepdeprivation

Typical sleep hygiene practices are often not usefulfor those with FASD as interventions need to betailored to individuals

Caregivers and professionals should work togetherin a team

Modifying the school/social environment is important

The rich learning experience that is required fortypical children may lead to over-loading anddisturbed sleep for children with FASD

Sleep Tips for Caregivers

The children’s reactions to the environmentshould always be carefully observed

The bedroom needs to be quiet, comfortable(i.e. bedding), familiar, secure, consistent andunexciting (i.e. no bright lights and colors)

Do not use the bedroom for punishment orplay.

Sleep Scheduling& Preparation

Calming behaviours and wind-down rituals

Caffeine and chocolate, excessive mental andphysical behaviors, and TV and video games shouldbe avoided in the evening

Enforcing rules, structure, routine and consistency areimportant throughout the entire day and at bedtime

Times for going to bed and getting up need to beconsistent, even during weekends and holidays

Melatonin replacement therapy for the child combinedwith sleep health promotion techniques may be usefulto establish

Case Review #3Demographics: Female, 12 years of age

Characteristics: Severe language disorder affecting all language

areas Often has difficulty sleeping Does not enjoy school Swears, kicks and hits when she gets angry Negative experiences in foster homes in the past

Final Diagnosis: ARND with confirmed maternalalcohol exposure, psychomotor delay, ADHD (bothtypes) and severe language disorder

Protective Factors

Streissguth et al. identified five protectivefactors that resulted in lower rates ofsecondary disabilities:

A good quality stable home environment

Infrequent changes in living arrangement

Not being exposed to violence

Receiving services for developmentaldisabilities

Being diagnosed before six years of age

Concluding Remarks

FASD is a life-long condition with implicationsfor behaviour, mental health, and adaptiveand executive functioning While symptoms ofFASD have their own manifestations, theyalso manifest in symptoms of behaviour,mental health, and adaptive and executivefunctioning

Care for children with FASD and itssecondary disabilities must be flexible andlife-long

References